Ruminations by a non-academic general surgeon from the heart of the rust belt.

Thursday, March 3, 2011

The "Tyranny" of the Open Breast Biopsy

I found this article via the NY Times. A Florida study assessed the rate of needle versus surgical breast biopsies over a period of five years. What we're talking about here are non-palpable abnormalities that are identified on screening mammography. A mammogram report will come back that assesses the relative risk of an abnormal collection of calcifications harboring an invasive or pre-invasive cancer (staged on a scale from I-V). With such data, one is obligated, as the patient's advocate, to prove whether or not the mammogram represents true or false positive findings. This means doing a biopsy.

Two ways to go about clarifying the cancer/no cancer conundrum: A needle biopsy is scheduled in the department of radiology. The interventional radiologist uses the stereotactic images to advance a specialized needle into the midst of the concerning area and subsequently vacuum aspirate several "cores" of tissue. The technique is not without complications, but is generally very well tolerated without the complications seen from surgical biopsies (bleeding, infection, unsightly scars, etc). The sensitivity approaches 97-99%. A negative needle biopsy, although reassuring, still demands that close follow up is necessary, i.e. re-imaging of the breast within 3-6 months.

The open biopsy is a surgical procedure. And it involves two phases. One, a woman has to go to the radiology suite for directed placement of a wire such that the tip resides in the hot zone of concern. She then is wheeled to the surgical area where she is sedated and anesthetized. The surgeon then makes a 2-5 cm incision in the skin and excises a lump of breast tissue containing the area of concern, using the pre-placed wire as a guide. She goes home the same day. Bleeding and infection complicate 1-3% of these procedures. Sensitivity is 100% and, if a cancer is confirmed, phase one of treatment has already been accomplished (excision of tumor).

This is the conversation, along with the options presented, that surgeons across the country have with patients who are referred to us with an abnormal mammogram. According to the paper cited above, 70% of women opt for the needle biopsy approach, while 30% are undergoing open surgical excision. My personal feeling is that it's always better to start small/less invasive and expand the armamentarium as needed. Acording to the authors of the paper, and other leading light Breast Surgeons, the idea that 30% of breast biopsies in this country are being done via the open approach is a miscarriage of justice akin to the 30 year torture/dictatorial regime of Mubarak in Egypt. (Seriously, some eminent scholar of supreme reknown named Melvin Silverstein, breast surgeon extraordinaire in California, actually compared lowering the 30% open biopsy rate to the recent uprising in Egypt to overthrow Mubarak. I'm not kidding.)

The study found that the open biopsy rate of Academic Breast Surgeons was about 10%. Private practice general surgeons conversely performed open biopsies 37% of the time. The discrepancy was attributed to several factors--- lack of knowledge by podunk non-academic surgeons, and pure greed being the main ones. Because, you know, if a surgeon refers a woman to a radiologist for biopsy of a suspicious lesion, then s/he loses the cost opportunity for an open excision. Only the holy white tower of academia prepares one for a surgical career free from financial incentive, didn't you know?

I love this passage from the NY Times article, again from the esteemed Dr Silverstein:

One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot.

“We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.”

What a tool. Hey Dr Silverstein guess what? Not every freaking surgeon who takes care of patients with abnormal mammograms lives within two seconds of a giant tertiary care center with experienced, reliable interventional radiologists and pathologists available at all times. We don't all spend our Tues and Thurs morning sipping coffee for three hours in multidisciplinarian breast oncology conferences. Some Americans actually live in the rural midwest and sparsely populated western plains. Furthermore, surgeons who do fewer breast biopsies per year than a dedicated breast oncologist will have inflated stats if a few patients opt for the open approach. Also, some women actually prefer the option of surgical removal. Even if the needle biopsy is negative, the lesion may still show up on a subsequent follow-up mammogram. The report may call it "suspicious" or maybe it will be down- graded to "close follow up recommended". Either way, she must continue to live with it, knowing she harbors something "not quite right", albeit almost assuredly benign, in one of her breasts. Some women, believe it or not, just don't like to have to carry around that secret knowledge. Some women stop you short when you get to discussing the minimally invasive options: "just take it out", they say.

Again, I am a strong proponent of stereotactic needle biopsies for the initial assessment of a concerning mammographic lesion. But this pompous posturing by some in the field of academic breast surgery is simply intolerable. Non fellowship trained surgeons who perform lumpectomies and mastectomies are fully capable of staying up on the medical literature. We are adept at following best treatment guidelines. You don't need a special little framed fellowship certificate on your wall to have an informed, back and forth conversation with with a patient in a very vulnerable position.

11 comments:

I agree. Also, before being so very categoric about things, Dr Silverstein might like to remember that both fine needle aspiration, and core biopsies DO incur the risk of upstaging an in-situ ductal carcinoma, on top of the false positives/negatives. This is not a plea for open biopsy, but merely an apeal to keeping an open mind about this.

I made the enormous mistake of actually reading some of the comments posted after the Times article - a mix of confused or defensive patients and echoes of the vilification you point to in the article. It is very unfortunate that across a large number of issues there is such harsh, patronizing criticism by academic medicine towards the much larger number of physicians actually sitting in front of patients every day. These issues are mostly not as black-and-white as they are often portrayed, and it seems cold and robotic to be made such a slave to the latest proclamation of a '2.2% reduction (p<0.05)' for all of the reasons you point out. As in almost everything these days, we could all benefit from a more moderate tone of discourse.

This reminds me of the laws that set minimum sentences and leave judges no discretion in legal cases. Sometimes situations require real decision making by smart and compassionate doctors and judges and not arbitrary rules.

The thing that many articles like this one seem to neglect is that the patient should be the one making the decisions. If we do our jobs well, our patients understand the diagnosis, treatment options, risks, potential complications, efficacy, recurrence rates, etc. These studies give us the statistics we emphasize to the patient. It's been my experience that if the patient thoroughly understands their options, they almost always make the right decision...for them.

It's not surprising that a dermatologist would have that opinion. Nearly all dermatologists, in my humble opinion, care only about money. Most patients have no idea what to do in these situations, and can easily be swayed by the treating doctor. A gentle "push" to the more lucrative option lines your pocket, and allows you to rationalize your greed by saying "it was the patient's decision and clearly was best for her." I'm not buying what you're selling, Florida derm. I'm glad to see that Buckeye's default option is to push to the less invasive option.

I'll ignore the ignorant generalization of my medical specialty and my professional ethics (which has no place in this forum), and acknowledge the possibility that patients can be pushed toward a more expensive treatment option. Our ethics should prohibit us from encouraging a treatment because it reimburses better.

I find it insulting to my patients, however, to assume that they aren't capable of understanding their choices. Our challenge is to inform and teach them about the statistics, risks, and benefits. I usually find them remarkably adept at making good choices, once they are educated and have the opportunity to ask questions. Published 'treatment guidelines' and 'recommendations from expert consensus panels' are powerful instruments to present to patients, and they're very persuasive. Patients always appreciate being actively involved in the decision making process. It's empowering, and it improves compliance.

Very well-said doc. My mum had breast cancer and she had two of these procedures. You are too right that some women just want their doctors to take it all out. Having no breast is better than having one with "abnormalities". Patients do have a choice and no doctor has the right to make such rules.

That's because this conversation occurs in a slightly different dimension among healthcare people. It's not about what Attorney Andy thinks it is, exactly. That is why he is unable to understand what florida derm means in her comment.

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